Amputation is a major health burden on the families, society, and on medical services as well. Traumatic limb amputation is a catastrophic injury and an irreversible act which is sudden and emotionally devastating for the victims. In addition, it causes inability to support self and the family and driving many patients toward various psychiatric disorders. Extensive information regarding the effects of amputation has not been ascertained and therefore it was decided to do a systematic review. The goal of this review was to provide comprehensive information of peer-reviewed papers examining the psychological distress among amputees in India. A search of the literature resulted in a total of 12 articles with varied sample size from 16 to 190. The sample has been largely comprised males with lower limb amputation caused by primarily traumatic ones, i.e., motor vehicle accident, railway track accidents, machinery injury, blasts, etc., The prevalence of psychiatric disorders among amputees has been found to be in the range of 32% to 84% including depression rates 10.4%–63%, posttraumatic stress disorder 3.3%–56.3%, and phantom limb phenomenon 14%–92%. Although the studies reported that symptoms of anxiety and depression become better over the course of time, however surgical treatment providers need to liaise with psychiatrists and psychologists to support and deal with the psychological disturbances.

Amputation of the limbs has been reported to a significantly stressful event for an individual.[1],[2] Amputation as a surgical option is resorted to in circumstances where salvaging a limb is improbable, and the remaining part of the limb tissue needs excision.[3],[4] Surgical amputation of a limb can be an elective procedure or an emergency procedure. The typical indications of amputation include trauma, infections, and neoplasms. Sometimes trauma inflicted during accident or blast may result in partial amputation which needs to be surgically completed to avoid complications.[5] Diabetes represents another condition when diabetic foot may require amputation when putrefaction starts to appear.[6],[7]

Amputation represents an irreversible surgical option which may result in physically challenged and bodily disfigurement. Many researches in the field of amputation reported that traumatic loss of a limb is typically equated with loss of spouse,[8] loss of one's perception of wholeness,[9] symbolic castration, and even death.[10],[11] This may result in the patient being severely affected emotionally and result in poor quality of life.[12],[13] The loss of the limb may cause distress not only due to the loss of a body part but also due to the role limitation and the need for adjustment to the changed lifestyle options. The individual undergoing amputation may be at risk of developing depressive disorder due to multiple factors such as feelings of loss, self-stigma, and difficulty in coping up with the impairment.[14],[15] The distressing events leading to the amputation, especially if amputation is induced by accident or blast, may induce symptoms of posttraumatic stress disorder (PTSD).[16],[17] Thus, amputation as an event produces considerable stress and challenges the coping of the individual.

India is a vast country with a large number of individuals in the community with various disabilities. It had been estimated that there are roughly 0.62 amputees in India per thousand population.[18] This translates to close to one million individuals with amputations in the country. The sources of emotional support are probably different from India than the Western world as the familial ties are stronger and provide close supervision and support.[19] Moreover, the health-care service delivery characteristics in India differ considerably than elsewhere, with mental health care access being difficult and fragmentary. Understanding the experiences of amputees in the Indian context might be helpful to know the extent of the problem and the direction of further research or service delivery upgradation. Hence, this review explores the Indian literature on psychological morbidity in patient who has undergone amputations.

Methodology

The present study aimed to collate the findings from observational studies reporting psychological distress among amputees in India.

Search strategy

The search strategy included electronic search engine databases: PubMed, PsychInfo, and Google Scholar. The keywords for the search were amputation, India, and psychological distress OR depression OR anxiety OR posttraumatic stress disorder. The searches were carried out in August 2015. Searches were independently conducted by authors. In addition, further studies were identified from the cross references. Unpublished material and nonpeer-reviewed material were not included as a part of the review, and hand searches of libraries were not conducted as a part of the present review.

Study selection

The present review included observational studies published in peer-reviewed English language journals pertaining to psychological distress. Case reports were not included in the present review. Nonlimb amputation was also not included in the present review. Those studies which did not report the prevalence of psychological distress in the study sample were not included.

Data extraction

All relevant abstracts were reviewed independently by investigators. After the initial evaluation, 16 abstracts were selected for further evaluation. Full texts of these abstracts were searched. Upon careful reading of the studies, 4 of 16 were not included in the review as they did not report the prevalence of psychological distress in the study sample.[18],[20],[21],[22] They were analysis and discuss the epidemiology, services and rehabilitation of amputees in India,[18] prevalence, etiology, levels of amputation,[20] rehabilitation after amputation,[21] and effect of anxiety, and depression on unilateral transtibial amputees.[22] Thus, rest of 12 studies were included for review.

Results

The review included 12 published articles based on ten study samples as mentioned in [Table 1]. The sample sizes of the studies have varied from 16[28] to 190.[29] The sampling method have varied from being consecutive to nonrandom purposive. The sample has been largely comprised young adult Hindu males. Most of them were married, educated approximately primary grade, and currently employed. The causes of amputation had been primarily traumatic ones (accidents-motor vehicle accident and railway track accidents, machinery injury, blasts, etc.) although other causes were also represented in the sample of amputees. In addition, lower limb amputation was noted in majority of cases than upper limb amputation and among them, most amputation performed with one limb.

Psychological morbidity had been reported in a considerable proportion of cases. There was heterogeneity in the assessment of psychological morbidity in the population of amputees. Assessment methods included clinical impression and diagnosis,[24],[26],[29],[32] as well as used of structured scales such as Beck Depression Inventory,[30] Beck Hopelessness Scale,[23] Carroll Rating Scale for depression,[25] General Health Questionnaire,[25] Hamilton Anxiety Rating Scale,[24],[34] Hamilton Depression Rating Scale,[24],[34] Hospital Anxiety Depression Scale,[33] Mini-International Neuropsychiatric Interview [27],[28] State-Trait Anxiety Inventory,[25] Structured Clinical Interview for DSM Disorder,[34] and Trauma Symptom Inventory.[33]

The presence of any psychiatric disorder was found in 32%–84%[26],[27] of the sample. The rates of depression reported in the studies varied from 10.4[32] to 63%.[28] Rates of PTSD have ranged from 3.3%[24] to 56.3%.[29] Generalized anxiety disorder rates ranged from 3.4%[32] to 10%.[27] Follow-up studies show that rates of anxiety and depression decrease over a period of time.[24],[25],[33] Phantom limb phenomenon had been observed in a considerable proportion of patients with amputations (14%–92%) associated with pain, telescopy, and movement.[26],[27],[31],[34]

Discussion

The present review suggests that Indian literature pertaining to psychological effects of amputation has gradually accrued over time. The studies have been heterogeneous and have attempted to understand the psychological impairment and psychiatric disorders among the amputees from different perspectives. The studies though have been consistent in finding that a substantial proportion of those individuals who undergo amputation do suffer from psychological distress and psychiatric disorders.

The prevalence of psychiatric disorders among amputees has been found to be in the range of 32%–84%. These rates are generally high as compared to population-based psychiatric prevalence studies conducted in India.[35],[36] However, the case–controls studies in the present study provided an inconclusive picture. The study by Bhojak and Nathawat [23] found a lower level of hopelessness among surgical controls, while the study by Mozumdar and Roy [30] found a comparable level of depression among “non-amputated healthy males.” The rates of depression and PTSD also have been alarming in some of the studies.

The findings of this review call for adept management of the psychological distress among the amputees. Depression and anxiety are common problems among patients who have suffered from amputation. Both the antecedent circumstances preceding the amputation and the irreversible procedure of amputation itself may contribute to the occurrence of symptoms of psychological distress. The surgical treatment providers need to liaise with psychiatrists and psychologists so that a comprehensive evaluation occurs when required and treatment of psychiatric disorders if identified can be initiated. The patient may be benefitted by both psychotherapeutic interventions and pharmacological management options. Previous literature suggests that symptoms of anxiety and depression become better over the course of time although patient may need support from various sources while coming to terms with the impairment.

The present corpus of literature from India presents opportunities for further research. The numbers of studies which have followed up patients over a period of time are quite limited. Since Indian social support system and health-care delivery services are quite different from the Western world, the changes with time in the psychological distress and psychiatric morbidity can give a glimpse of remedial and accentuating factors. Moreover, studies need to consistently need to use standardized methods of making psychiatric diagnoses and eliciting symptoms using scales. This would help to compare the studies more accurately. Consistent subgroup analysis of traumatic and nontraumatic amputations can help discern the acuity of the psychological distress in these two groups. Moreover, intervention studies need to be conducted to assess the effectiveness of interventions among the amputees in the local context.

Muzaffar N, Mansoor I, Arifa H, Margoob MA. Psychiatric comorbidity in amputees with average sociodemographic status and the role of theologic and family support in a conflict zone. Australas J Disaster Trauma Stud 2012;2012:31-8.